HomeMy WebLinkAboutSeptic Pumping Slip - 81 BRADFORD STREET 9/10/2015 Commonwealth of Massachusetts
_ City/Town of .
System Pumping-Record
Form 4
DEP has provided this form for usez by local Boards of Health. Other forms may be'used, but the
information-must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
1. System Location: Left
y -h front of hour, Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right ron o building, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner.
I
Name'
Address(if different from location)
CitylTown Stag ip Code
Telephone Number
B. Pumping Record �.
1. Date of Pumping 2. Quantity Pumped: —�
Date Gallons
3. Type-of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System
.. ,
6.. System Pumped By:
Neil.Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Location where contents-were disposed:
G L S Lowell Waste Water
Sign a 9t Haule4j Date
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